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<br />STATE OF NEBRASKA
<br />•, WHC�I THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVIGES, lT CERTIFIES �
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF H�'ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA� RECORI�S�' ��,; �, ,' ', I
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<br />DATE OF ISSUANCE '`
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<br />STAN4 .a. ��OP�� �"i;�` . �-�
<br />. � �cr 1� 20�0 2 0 i 10 2 4 9 9 AS�r�- .ANT�STA�B�IST�4R •� �Q, :-
<br />DEP�SY,�!!�E O �' L]',�-I i4N�� �,� -
<br />, � LINCOLN, NEBRASKA HUM'1��M S�A� � � ' : �• .�"
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<br />, 3TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�Sr �'`�i +'� !� '
<br />CERT FI E OF DEATH `� � • •. �� �° � � �
<br />` 7. DECEDENT&NAMH (Fl�et, Mlddie, Last, -. . Su66c) 2 SDf + r OlyTE bP'DLATH. (MO..Oay.Yc)
<br />1
<br />Ben Lavere Schoneberg Male October 1, 2010 i
<br />0. CITY ANO STATE OR TERRITORY, OR FOREItiN 60lINTRY OF BIRTH 8a AGE-Last Blrthdey Bb. UNDER 1 YEAR Bc. UNDER 1 DAY 8. �ATE OF BIRTH (Mo., Gay, Yc)
<br />(yrs.) MOS. DAYS HOURS MINS. •
<br />Wood River, Nebraska 85 February 23, 1925 �
<br />7. SOCIAL 8ECURITY NUMBER 8a PLACH OF DEATH
<br />506-22-6208 o�A�'. � Naedent pTHER: Q Nu[sing HomNLTC � Hoaplca Faeiltty • i
<br />V Bb. FACILITY•NAdAE (It �rot IrtetltuUon, 91va atreet and numbe� - - ❑�D��BM f �� DeaeiisN'e Homa -- ----- - -- - I
<br />Veterans Affairs Medical Center ❑ �A ❑ocneKs�rv�
<br />Ba CITY OR TOWN OF DEATH (Ineluda �p Codaj 8d. COUN7Y OF DEATH
<br />Grand Island 68803 Hall
<br />Ba. RESIDENC85TATE 9b. COUNTY Bc. CITY OR TOWN
<br />Nebraska Hall Grand Island �
<br />� 9d. STREET AND NUMBER ee. APT. NO. eL ZIP CODE 9g. INSIOE CITY LIMRS
<br />� 206 Wetzel St. 68801 � v� ❑ No
<br />� 10a. MARITAL STATUS AT TIA78 pF DEATH � 66artied �❑ Nerer married 10b. NAMB OF BPOUSE (Flret, �Mfddle, Laet, Suff(x) H wite, give maiden mm�a. -. �
<br />� � INaRled, put sepereffid Q Widowed ❑ Diwrcad ❑ Unknown Eunetta Mam1e Rathman
<br />m �
<br />E � 11. RATHER'S-NAML' (Flrst, Mlddle, Last, . SuffGc) 12 MOTHER'&NAEAB (Ffrat, MldrDe, Malden Swneme)
<br />� Ben � Emil Schoneber Vera Tuffs
<br />m� 13. EVER tN U.B. ARd1ED FORCEB? Olre dates oT aervice ItYea 14a INFORMANT-NAME 14b. REIATIONSHIP TO OECEDENT i
<br />� n�, No, o� u�.� Y� 1/ 2 7/� 5-1 1/ 17J 4 6 Eunetta Mamie Schoneber Wife _
<br />1& d1ETHOD OF DISPOSITION 18a. EINBALMER-SIGNATURE , 186. LICENSH NO. 18a DATE (Mo., Day, Yr.)
<br />0�'"e � Not Embalmed October 2, 2010
<br />�Cmm�ation QEmamMrent - .. STATE , i
<br />❑�� ❑ �� e � l 18dCEMETFRY.CREMATORYOROTNERLOCATfON C�1'1fffOWN I
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a FUNERAL HOME NAME AND MAILINQ ADDRES8 (Street, C(ty or Tovm, State) � � � i
<br />, All Faiths Funerel Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (S�e instructions and examples) �
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<br />'I& PAI1T 4 E�ner Itre cNetn oleventa. tliaeaee& inhrtlea. or eomPbeaHovs-Umt �aeHY eeused thn AealL. DO NOT eNer � BveNS eutd ea eazdiao ertasL � APPROXIMATE INTERVAL . I
<br />�P�f' erteef. otvenMcule� INrillation wNhout ehoarin8 Ne eNCIuBY. DO NOT ABBREVW7C EMe�onb otre muee on e Me. Ad6 eGElHenal Qr2e E nec�mry• � �--
<br />16Ad1EDIATE CAUSE: i mreet to death
<br />° tlNMED1ATE CAUSB (Flnal j -
<br />disease or oomONon reauidng e) �. � .
<br />in death)
<br />OUE T0, OR AS A CONSE ENCE OF: � o�reet to death
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<br />Sequentle�ly Uet ¢ondltlo�re, It b) �
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<br />I arry, leading to the cauea Iiated
<br />on Urte a. DUE TO, OR AS A CONSEQU CE OF: � onseY to death
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<br />Enter the UNDERLYINO CAUSE a) � 0 � d bc o;, � o. � � R � I
<br />�� ( ��� e ����� ����� DUE TO, OR AS A CONSEQUENCE OF: , � � onaet to death I
<br />I fhe eveMe resufHng In death) � �
<br />LAST � I
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<br />� � 78. PART II.OTHER SI6MFlCANT CONDITIONSConrlltlona wntribudng to death but mt resW e imderiyln8 8�ven In PAR7 L 1& WAS AAEDICAL E%AMINER i
<br />� - ��C�I�S�d"n ORCORON CONTACTED7 i
<br />\ ❑ YES �NO �
<br />� � .` T ' 1 �1 f�d� OP C �
<br />�� yp. IF FE�ALE; 27a MANNER OF DEATH 216. IF PORTA 21c WAS AN Al1tOP3)' PERFOREAm? �
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<br />H'', ❑Not pra8� withln Pest Y�► Neturel ❑ Homlcida ❑ Drive�lOperator ❑ YES NO i
<br />W I OPregnant at dme ot death ❑ AcddeM ❑ Pemm�g Imrestlgetlon ❑ Passangar �d, WERE pUTppgy FINDINGS AVAI� ea� e
<br />V � ❑Not pregnent, but ptegnent witliln 42 days M de�h ❑ Sulc[da ❑ CoWd rrot be detmmined ❑ PedeaMan TO COd1PLETH CAUSE OF DEA1'H9 !,
<br />,p I ❑ Not pregnent, but pre8nant 43 deye to 1 year before deeth ❑ Othar (8pee1(y) � YES ❑ NO
<br />� I �UnknownHpreBnm�twkhinthapaetqaer i
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<br />O � 82a DATE OF INJURY (dla, Day, Yr.) 22b. TIME OF iNJURY 22m PLACE OF INJURY•At hortre. farm, aVeaR tatltory� offlce buildMg, eanatruetion site, ete. (Speelty)
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<br />, o I 22d. INJUR T W RK? 22a. DESCRIBE HOW INJURY OCCURRED . I
<br />F ❑ YEJ NO _ - -_ - - - I
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<br />22L LOCATION OF INJURY - 8TR6ET & NUMBER, APT. NO. CIiYlTOWN STATE � ZIP CODE
<br />23a' DATE OF DRATH (Mo., Dey, YG) ��� 24a. DATE SI6NED (INo., Dey, Yr.) � 246. TIME OF DFJITH
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<br />� 23b. DATE 81(iNED (Mo„ Gay. Yr.) xic. TIME OF �EATH � Y O� 24e. PRONOUNCED OEAD (Mo., Day, Yr.) 24d. TImE PRONOUNCED OEAD �
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<br />23d. To tha beet ot my Imowledqe, deffih oecurred et the 6me, dete and plaee Z 24e. On the bes�s ot exeminatlon enNor InvesdB��M M mY oplNon deat0 aee�med �
<br />, F�• d aue w me eauae(a► smmd. (s�¢,�ma ana nee� ,$ � o es we nme� date and plaee a�M due to the cauee(s) etatad. (S1gneMe end Titte) i
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<br />26. DID TO CCO USE CONTRIBUTE TO E D THT 26a. HA9 OROAN OR TI U DONATION BEEN CONSI�ERED7 28b. WAS CONSENT 6RANTEDT i
<br />❑ YES ❑ NO ❑ PROBABLY NKNOWN � YES NO Not Appllceble ff ZBa te NO ' ❑ YES NO
<br />27. NAME� TITI.E AND AODRE.98 OF CERTIFlER (PHYSICIAN, PHYS�CIAPJ ASSISTANT CORONER'8 PHYSICIAN OR COUNTY ATTORNEI7 (Type oi P�Ltt) '
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<br />28a. RE6ISTRAR'8 St6NATURE ' � 2Bb. DATE FlLED BY REGISTRAR (AAo., Day. Yt.)
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